The development of a district-based model of intervention for improving the quality of maternal health care at primary level.

Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2005.The Limpopo MCWH Directorate, concerned about the high perinatal and maternal mortality rates arising from the poor quality of maternal health care provided at primary level, commissioned this study to explore what would be the appropriate interventions that could be applied province-wide to improve the quality of maternal health care at municipal and district level. Thus the study aimed to develop a useable and replicable model of intervention with Reproductive Health Management Teams (RHMTs) at municipal and district level that would lead to improvements in the quality of maternal health care. The study objectives were to: 1. Identify indicators and the method for a baseline assessment of the quality of maternal health care at municipal and district level. 2. Identify indicators that would permit an analysis of the factors that influence the key issues emerging from the baseline assessment. 3. Develop a programme of intervention, with its monitoring and evaluation procedures, that would address the factors that influence the key issues. 4. Recommend a strategy for replicating the intervention programme. An action-research approach was adopted in this study, and was implemented in a series of cyclical action-research steps in cooperation with the RHMTs. The study was implemented in 25 municipalities in Limpopo Province and was implemented over a period of 28 months, from December 2001 to March 2004. Both qualitative and quantitative methodologies were used. Indicators were identified to conduct a baseline assessment of the quality of maternal health care; the tools were developed to collect the data necessary to calculate these indicators; the indicators were applied to achieve a baseline assessment of the quality of care, and the information analysed to identify priority key issues affecting the quality of maternal health care. These key issues were identified as: the poor quality of the 1st ANC visit and poor management of labour. These key issues were analysed in order to identify what were the most important influencing factors affecting the quality of maternal health care. Staffing, supervision, referral systems, support services and the planning and organisation of the health facilities were found to be the most influential factors. Indicators were developed to measure these factors, with the data collection tools required to collect the data necessary to calculate the indicators. The indicators were measured to describe the current situation with regards to each. Once the influencing factors had been identified, interventions were identified, prioritised and planned for implementation in each municipal area. The priority interventions that could be implemented at municipal level were: in-service training in antenatal care and the management of labour; supervision of antenatal care and labour; audit of the service and improving referral systems. Tools were developed to monitor the implementation of these interventions and the outcomes of monitoring reported. The model to improve the quality of maternal health care developed in Limpopo Province is possible to implement within the context of health services in South Africa. A limiting factor to full implementation may well be staffing shortages, although this study did not set out to establish the degree of influence that staffing shortages do actually exert. The real challenge to full implementation, however, lies in the ability of managers at different levels to work together to support quality service delivery, and for providers to deliver an integrated, comprehensive service to pregnant women. Municipal and district level Reproductive Health Management Teams, with a full mandate and good leadership, managerial, clinical and public health skills, have the potential to address the most critical factors at the local level that are influencing the quality of care

Discontinuation of cART postpartum in a high prevalence district of South Africa in 2014

BACKGROUND: Combination antiretroviral therapy (cART) is the current strategy to prevent mother-to-child transmission (PMTCT) of HIV. Women initiated on cART should continue taking treatment life-long or stop after cessation of breastfeeding depending on their CD4 cell count or on their World Health Organization (WHO) staging. Keeping people living with HIV on treatment is essential for the success of any antiretroviral therapy (ART) programme. There has been a rapid scale-up of cART in the PMTCT programme in South Africa. cART is supposed to be taken life-long or until cessation of breastfeeding, but premature or unmanaged discontinuation of cART postpartum is not unusual in South Africa and is confirmed by studies from around the world. Discontinuation of cART can lead to mother-to-child transmission (MTCT), drug resistance and poor maternal outcomes. The extent of this problem in the South African context however is unclear. This study aims to determine the prevalence of and identify risk factors associated with discontinuation of cART postpartum amongst women who were initiated on antiretroviral treatment during their index pregnancy. METHODS: An observational analytic cross-sectional study design will be conducted in six health facilities in a high prevalence district in KwaZulu-Natal, South Africa over a period of 3 months in 2014. An interviewer-administered questionnaire will be used to collect data from mothers who initiated cART during their index pregnancy. The prevalence of discontinuation of cART postpartum will be measured, and the association between those who discontinue cART postpartum and independent variables will be estimated using multivariable-adjusted prevalence odds ratios for discontinuation. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s13012-014-0139-3) contains supplementary material, which is available to authorized users

Prevalence and factors associated with low back pain among nurses at a regional hospital in KwaZulu-Natal, South Africa

Background: Low back pain (LBP) is a public health problem worldwide and is a common cause of work-related disorder among workers, especially in the nursing profession. Recruitment and retention of nurses is a challenge, and the nursing shortage has been exacerbated by the burden of occupational injuries such as LBP and related disabilities. The physiotherapy clinical records revealed that caseload of nurses presenting for the management of LBP was increasing. The prevalence and factors associated with LBP were unclear. Methods: A cross-sectional study design with an analytic component was implemented. Data were collected utilising a self-administered questionnaire to determine the prevalence and factors associated with LBP among nurses at a regional hospital. Bivariate analyses were performed to determine the factors associated with LBP. Results: The point prevalence of current LBP in nurses was 59%. The highest prevalence was recorded among enrolled nurses (54%), respondents aged 30–39 (46%), overweight respondents (58%) and those working in obstetrics and gynaecology (49%). Bending (p = 0.002), prolonged position (p = 0.03) and transferring patients (p = 0.004) were strongly associated with LBP. Nurses with more than 20 years in the profession reported a high prevalence of LBP. The prevalence of LBP was higher among the participants who were on six-month rotations (76%) compared with those on yearly rotation (16%). Conclusion: A high proportion of nurses reported to have LBP. Occupational factors are strongly associated with LBP. Education programmes on prevention and workplace interventions are required in order to reduce occupational injuries

Stages of change: A qualitative study on the implementation of a perinatal audit programme in South Africa

<p>Abstract</p> <p>Background</p> <p>Audit and feedback is an established strategy for improving maternal, neonatal and child health. The Perinatal Problem Identification Programme (PPIP), implemented in South African public hospitals in the late 1990s, measures perinatal mortality rates and identifies avoidable factors associated with each death. The aim of this study was to elucidate the processes involved in the implementation and sustainability of this programme.</p> <p>Methods</p> <p>Clinicians' experiences of the implementation and maintenance of PPIP were explored qualitatively in two workshop sessions. An analytical framework comprising six stages of change, divided into three phases, was used: pre-implementation (create awareness, commit to implementation); implementation (prepare to implement, implement) and institutionalisation (integrate into routine practice, sustain new practices).</p> <p>Results</p> <p>Four essential factors emerged as important for the successful implementation and sustainability of an audit system throughout the different stages of change: 1) drivers (agents of change) and team work, 2) clinical outreach visits and supervisory activities, 3) institutional perinatal review and feedback meetings, and 4) communication and networking between health system levels, health care facilities and different role-players.</p> <p>During the pre-implementation phase high perinatal mortality rates highlighted the problem and indicated the need to implement an audit programme (stage 1). Commitment to implementing the programme was achieved by obtaining buy-in from management, administration and health care practitioners (stage 2).</p> <p>Preparations in the implementation phase included the procurement and installation of software and training in its use (stage 3). Implementation began with the collection of data, followed by feedback at perinatal review meetings (stage 4).</p> <p>The institutionalisation phase was reached when the results of the audit were integrated into routine practice (stage 5) and when data collection had been sustained for a longer period (stage 6).</p> <p>Conclusion</p> <p>Insights into the factors necessary for the successful implementation and maintenance of an audit programme and the process of change involved may also be transferable to similar low- and middle-income public health settings where the reduction of the neonatal mortality rate is a key objective in reaching Millennium Development Goal 4. A tool for reflecting on the implementation and maintenance of an audit programme is also proposed.</p

The dynamics of HIV transmission in out of school young heterosexual men in South Africa: a systematic scoping review protocol

PRISMA-P checklist. (DOCX 29 kb

A health system framework for perinatal care in South African district hospitals: A Delphi technique

The majority of perinatal deaths occurring in low- and middle- income countries are preventable. South Africa is a middle-income country with consistently high perinatal mortality rates and most factors contributing to preventable deaths are linked to the functioning of the health system. Particularly of concern in South Africa is the high perinatal mortality in district hospitals, where most births occur and where intrapartum care is provided to women of low and intermediate risk. Therefore, it is crucial to strengthen the health system for perinatal care in district hospitals. There is currently no consolidated documented framework outlining contextual health system domains and indicators that are key to providing effective perinatal care in district hospitals. The purpose of this study was to derive key health system domains and indicators necessary to measure the performance of the health system for perinatal care in South African district hospitals. Methods: The Delphi technique was used in collecting data from a panel with experts drawn from disciplines connected with the functioning of the health system for perinatal care in South Africa. The study enrolled thirteen experts from whom data on key health system domains and indicators for perinatal care were derived. The project reference group gave guidance to the development of the framework and ascertained its relevance to the South African setting. Results: The Facility Based Health System Framework for Perinatal Care comprising domains and indicators necessary to measure health system performance in South African district hospitals was derived from data. The broad structure of the proposed framework aligns with the WHO Health Systems Framework. Each critical building block has detailed domains and indicators that illuminate essential facility-level and programme-specific elements that require attention for strengthening the health system for perinatal care. Conclusion: The proposed framework can enable district hospital management teams to identify gaps in the health system for perinatal care, which need to be strengthened in order to alleviate the burden of perinatal deaths in district hospitals

Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa

Sub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems ‘hardware’ and ‘software’ issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. ‘Hardware’ and ‘software’ constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the ‘problematic’ of compromised TB-IPC, highlighting the importance of capturing dimensions of the ‘enabling environment’, currently not assessed in binary checklists

Beyond checklists: Using clinic ethnography to assess the enabling environment for tuberculosis infection prevention control in South Africa

From PLOS via Jisc Publications RouterHistory: collection 2022, received 2022-05-04, accepted 2022-10-12, epub 2022-11-09Acknowledgements: We acknowledge the important contributions of Gimenne Zwama, Thandeka Smith and Zama Khanyile in conducting and documenting the ethnographic fieldwork in KZN. We are grateful to the health clinic managers and health workers for their time, interest, and motivation to participate in this study. We thank our colleagues from the Umoya omuhle project for the rich inter-disciplinary discussions and exchange of ideas.Publication status: PublishedFunder: Economic and Social Research Council; funder-id: http://dx.doi.org/10.13039/501100000269; Grant(s): ES/P008011/1Funder: Bloomsbury Set, Research England; Grant(s): CCF17-7779Funder: Economic and Social Research Council; Grant(s): ES/P008011/1Funder: Wellcome Trust Strategic Core Award; Grant(s): Africa Health Research Institute, ref. 201433/A/16/ASub-optimal implementation of infection prevention and control (IPC) measures for airborne infections is associated with a rise in healthcare-acquired infections. Research examining contributing factors has tended to focus on poor infrastructure or lack of health care worker compliance with recommended guidelines, with limited consideration of the working environments within which IPC measures are implemented. Our analysis of compromised tuberculosis (TB)-related IPC in South Africa used clinic ethnography to elucidate the enabling environment for TB-IPC strategies. Using an ethnographic approach, we conducted observations, semi-structured interviews, and informal conversations with healthcare staff in six primary health clinics in KwaZulu-Natal, South Africa between November 2018 and April 2019. Qualitative data and fieldnotes were analysed deductively following a framework that examined the intersections between health systems ‘hardware’ and ‘software’ issues affecting the implementation of TB-IPC. Clinic managers and front-line staff negotiate and adapt TB-IPC practices within infrastructural, resource and organisational constraints. Staff were ambivalent about the usefulness of managerial oversight measures including IPC protocols, IPC committees and IPC champions. Challenges in implementing administrative measures including triaging and screening were related to the inefficient organisation of patient flow and information, as well as inconsistent policy directives. Integration of environmental controls was hindered by limitations in the material infrastructure and behavioural norms. Personal protective measures, though available, were not consistently applied due to limited perceived risk and the lack of a collective ethos around health worker and patient safety. In one clinic, positive organisational culture enhanced staff morale and adherence to IPC measures. ‘Hardware’ and ‘software’ constraints interact to impact negatively on the capacity of primary care staff to implement TB-IPC measures. Clinic ethnography allowed for multiple entry points to the ‘problematic’ of compromised TB-IPC, highlighting the importance of capturing dimensions of the ‘enabling environment’, currently not assessed in binary checklists

Health system influences on the implementation of tuberculosis infection prevention and control at health facilities in low-income and middle-income countries: A scoping review

Gimenne Zwama - ORCID: 0000-0001-9458-522X http://orcid.org/0000-0001-9458-522XKarina Kielmann - ORCID: 0000-0001-5519-1658 http://orcid.org/0000-0001-5519-1658Background Tuberculosis infection prevention and control (TB-IPC) measures are consistently reported to be poorly implemented globally. TB-IPC guidelines provide limited recognition of the complexities of implementing TB-IPC within routine health systems, particularly those facing substantive resource constraints. This scoping review maps documented system influences on TB-IPC implementation in health facilities of low/middle-income countries (LMICs).Methods We conducted a systematic search of empirical research published before July 2018 and included studies reporting TB-IPC implementation at health facility level in LMICs. Bibliometric data and narratives describing health system influences on TB-IPC implementation were extracted following established methodological frameworks for conducting scoping reviews. A best-fit framework synthesis was applied in which extracted data were deductively coded against an existing health policy and systems research framework, distinguishing between social and political context, policy decisions, and system hardware (eg, information systems, human resources, service infrastructure) and software (ideas and interests, relationships and power, values and norms).Results Of 1156 unique search results, we retained 77 studies; two-thirds were conducted in sub-Saharan Africa, with more than half located in South Africa. Notable sociopolitical and policy influences impacting on TB-IPC implementation include stigma against TB and the availability of facility-specific TB-IPC policies, respectively. Hardware influences on TB-IPC implementation referred to availability, knowledge and educational development of staff, timeliness of service delivery, availability of equipment, such as respirators and masks, space for patient separation, funding, and TB-IPC information, education and communication materials and tools. Commonly reported health system software influences were workplace values and established practices, staff agency, TB risk perceptions and fears as well as staff attitudes towards TB-IPC.Conclusion TB-IPC is critically dependent on health system factors. This review identified the health system factors and health system research gaps that can be considered in a whole system approach to strengthen TB-IPC practices at facility levels in LMICs.Funding The support of the Economic and Social Research Council (UK) is gratefully acknowledged. The project is partly funded by the Antimicrobial Resistance Cross Council Initiative supported by the seven research councils in partnership with other funders including support from the GCRF (grant reference: ES/P008011/1).https://doi.org/10.1136/bmjgh-2020-0047356pubpub

Tuberculosis infection prevention and control: why we need a whole systems approach.

Infection prevention and control (IPC) measures to reduce transmission of drug-resistant and drug-sensitive tuberculosis (TB) in health facilities are well described but poorly implemented. The implementation of TB IPC has been assessed primarily through quantitative and structured approaches that treat administrative, environmental, and personal protective measures as discrete entities. We present an on-going project entitled Umoya omuhle ("good air"), conducted in two provinces of South Africa, that adopts an interdisciplinary, 'whole systems' approach to problem analysis and intervention development for reducing nosocomial transmission of Mycobacterium tuberculosis (Mtb) through improved IPC. We suggest that TB IPC represents a complex intervention that is delivered within a dynamic context shaped by policy guidelines, health facility space, infrastructure, organisation of care, and management culture. Methods drawn from epidemiology, anthropology, and health policy and systems research enable rich contextual analysis of how nosocomial Mtb transmission occurs, as well as opportunities to address the problem holistically. A 'whole systems' approach can identify leverage points within the health facility infrastructure and organisation of care that can inform the design of interventions to reduce the risk of nosocomial Mtb transmission